Registration with Adverse Reaction

REGISTRATION WITH ADVERSE REACTION
If you are also a victim of adverse reactions you can register completely free of charge to our committee by filling out the form.

We need your testimony because only by witnessing can we be able to raise awareness among the scientific community and institutions.
We are waiting for you!

The registration is totally free.

* Required fields

Iscrizione

Surname*

Name*

Date of Birth*

Telephone*

E-mail*

Please tell us about your story (what symptoms you had/have, who you have been contacted by, what tests you have run …) It is essential for researchers and doctors to find hypotheses for diagnosis and treatments

Type of vaccine

Date of first shot

Date of second shot (if none, type 01/01/2021)

City

Date of eventual third shot (if none, type 01/01/2021)

Lot number, first shot

Lot number, second shot

Lot number, third shot

Lot number, fourth dose

Vaccination certificate

Upload file

ID Card - front

Upload file

ID Card - back

Upload file

Attivazione

I have read the Privacy Policy and I give my consent to the processing of my personal data for the exclusive purposes of the Ascoltami Committee

Contact info

E-mail: info@comitatoascoltami.it